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11907..APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING PROJECT IDENTIFICATION APPLICATION & PERMIT BUILDING - ELECTRICAL -PLUMBING -MECHANICAL PERMIT NUMBER 11907 BUILDING ADDWS Q -74 00 ^T��'a OWNER'S / D NAME LSO 1<19PLAN ZXAA QTY. ELECTRIC PERMIT FEE CHECK VALIDATION DATE OF APPLICATION MTRALTO SO LIC. NO. OUTLETS -SWITCHES-RECEP 10.00/1.00 LIGHTING FIXTURES 10.00/1.00 CONTRACTOR OH'S�A �Imo' ADDRESS JJ``LL WfnG q SII //�� rT 6 w PHONE �W�1� PPLIANCES-RESIDENTIAL 4,00 PANELS 10.00 ARCHITECT OR ENGINEER , uc, NO, PANELS (OVER 200 AMPI 20.00 PLAN CHECK FEE P.C. NO. SIGNS TRANS. 3.00 NG. ! ADDRESSH. A003 4l"J�3 SPECIAL CIRCUIT 5.00 PERMIT VALIDATION \ /, / as 7 ISSUANCE DATE BLp�. ELECT. PLG. MECH. f sL�y.\ EMP. METER OR POLE INS. 20.00 APPLICANT'S ADDRESS MOTORS SEE FEE SCH. SERVICE CHANGE 20.00 LICENSED CON TRACTORS DECLARATION 1 hereby affirm that 1 am licensed under provisions of Chaplet 9 (commencing with Section 7000) of Division'3 of the Business and Professions Code d my license is in full foK4' effec Dafen IS Lin. Numbe� Dale Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec. 7031.5, Businessand Professions Code: Any city or county which requires a permit to construct, also improve, demolish, or repair any structure, prior its issuance,, Mso requires the applicant for such permit to file a signed statement that he is licensed pursuant en the provisions of the Contractor's License of Division 3 of the Law (Chapter 9 (commencing with Section is exempt Business and Professions Code) or that he is exempt therefrom and the basis fur the alleged exemption. Any violation of Section 7031.5 by any applicamfora Permit subjects the applicant too civil penally ofnot more than five hundred do1lars($500L): ❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improve. mems are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or im- prove for purpose of Sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, BusinessLAWN and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant 10 the Contractor's License Law. ❑ lam exempt under See.., B.&P.C. for this reason BUILDING PERMITINFORMATION MISC. - REFER TO ORD PERMIT ISSUANCEVALUATION 10 .00 $/FT. ELEC. CONTR. LIC. NO. ELEC. TOTAL RIM TO R M / OTV. PLUMBING PERMIT FEE STORIES TYPE CONSTR. ALTER -DRAIN & VENT -WATER (EA.) 5.00 BACK FLOW PROTECT. DEVICE 4.00 OCC. GROUP RES. UNITS DRAINS -FLOOR, ROOF, AREA, COND. 5.00 FIXTURES - PER TRAP 5.00 GAS -EA. SYSTEM -11 NC.4 OUTLETS 6.00 SD. FT. FLOOR AREA TOTAL ACREAGE GAS - EA. SYSTEM -OVER 4 (EA.) 2.00 BUILDING USE RES IND CON PB Omer INDUSTRIAL WASTE INTER. 30.00 SPRINKLERS- 1 INC 5 V.B. 600 . LAWN SPRINKLERS - OVER 5 (EA.) 1.00 ASSESSORS PARCEL No. SEWER -SANITARY -STORM EA. 200ft/10.00 TRACT NO. PARCEL NO. WATER HEATER W/VENT 6.00 Owner Date WATER SYSTEM 5.00 WORK ERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to sell -insure, or a certificate of Workers' CompensaLLlon Insurance- or a Certified copy copy thereof (Sec. C., P.ny ere Company ❑ Certified Copy is hereby furnished. Cer(''ed c/)ry ,is fled with the cit it peon divisi n. PPlicunt ACC. DATE ACC. FILE NO. WATER TREATING EQUIP. 5.00 ZONING ENG. SITE NO. FIRE SPRINK V N ❑ ENERGY T-24 V N MISC- REFER TO ORD, CERTIFICATEOFEXF.MPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars IS 100) or less I I certify that in the performance of the work for which this per. Oil( is issued, I shall not employ any person in ;my manner so as ID become subject to the Workers' Compensation Laws of California. Date Applicant PERMIT ISSUANCE 10.00 FLOOD ZONE Y N A.L.U.C. v1:1 NEI PLG. CONTR. LIC. NO.PLG, TOTAL QTY MECHANICALPERMIT FEE FEE SUMMARY BUILDING N ALTER OR ADD TO MECH. 00 5. NOTICE TO APPLICANT: II'• after ..king this Certificate of Ex - emption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ.C.). APPLIANCE 5.00 AIR HANDLING UNIT (TO 10=r-F.M.) 4,00 PLAN CHECK FEE AIR HANDLING UNIT(OVER 10J"GflM.) 6.00 SEISMIC FEE EXHAUST HOOD )WITH DUCT) 5.00 MICROFILM HEATING UNIT (TO 100,000 B.T.U.) 8.00 Lender's Name Lender's Address HEATING UNIT (OVER 100,000 B.T.U.)9.50 ELECTRIC I certify that I have read this application and state that the above information is correct. 1 agree to comply with .11 City and county ordinances and slate laws relating to building construction, unJ hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities• judgments, costs and expenses which may in any way accrue against said City in consequence of the grantAing, of this Permit. ,�,''qq�� la,f �/i��CC/�-�e7 3-27'g7 VENTILATION FAN (SINGLE) 4.00 PLUMBING BOILER-COMP(3 H.P. or 100,000 B.T.U.) 6.00 BOILER -COMP Over 100,000 BTU) SEE FEE SCH. MECHANICAL MISC. - REFER TO ORD. PERMIT ISSUANCE 10.00 CONST. TAX MECH. CONT. LIC. NO. MECH. TOTAL TOTAL Signature ol'Applican[/Con[rc r Ua to 7 J^a _ ? / q sem. OFFICE COPY x 3 POST THIS CARD NEAR FRONT OF BUILDING CITY OF CUPERTINO INSPECTION DIVISION JOB INSPECTION RECORD JOB ADDRESS UNI # LOT # OWNER CONTRACTOR PERMIT NUMBER 11907 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN DAYS OF PERMIT ISSU- . ANCE OR 180 DAYS FROM LAST CALLED INSPECTION. INSPECTION DATE INSPECTOR I SPECTION RECORD 4180 FOUNDATION B LIFER PREGUNITE lC 3o k o is 6/zcr /40,c v> ' PERMIT VA LIDATION b k(7 ISSUANCE DATE POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED rJ 17-7�fl Ig��- �4• UNDERGROUND/SL B PLUMBING 7-% •l$ eM� C v ELECTRICAL MECHANICAL p0je B DG. ELECT. PLG. MECH. nv111;- 7) PO 6fr- 2,4S&AMl1r 7211 DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED 7-1ov % FSR A��r°< BU LOIN PERMPT WOOD FLOOR VALUATION $/FT. PLUMBING fl•/ -DFi � MECHANICAL ELECTRICAL y�,p�P, f - / PERMIT\ro K15, �VF-� FRAMING INSUL'A'TION STORIES TYPE CONSTR. w �;PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED 'AfAyaV mum, vileA ,0 OCC.GROUP RES.UNITS ROOF /°-'3j X79 a FLOOR AREA TOTALACHEAGE DIAPHRAGM S°TN Y/Sr/A/fn PL Cls Sr an/ BUILDING USE RES IND CON PB GO,., ❑ ❑ ❑ ❑ ❑ APPLY NO ROOFING UNTIL ABOVE HAS BEEN SIGNED ROUGH l/•13. / DO/ G Awat // ASSESSORS PARCEL NO. PLUMBING GAS TEST T ACT N0. PARCEL N0. MECHANICAL PrA_ ELECTRICAL FINALS DATE 'NSP. ACC. DATE ACC. FILE NO. FRAMING SAN.# INSULATION PLUMBING ZONING ENG. SITE NO. �D �/ GAS MEAA� i FIRE SPRINK Y ❑ N ❑ ENERGY T20 Y ❑ "❑ COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED HEA I LATH -INTERIOR EL IC FLOOD ZONE '' ❑ "❑ aL.0 c. v ❑ "❑ LATH -EXTERIOR FI OE SHEETROCK A FEESUMMARY SHEAR INTERIOR UIL G BUILDING SHEAR EXTERIOR TEMPORARY APPROVALS FIREWALLS E CTRIC PLAN CHECK FEE AS SEISMIC FEE NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED OCCUPANCY OCCUPANCY OF BUILDING ISNOTPERMITTED UNTIL BUILDING FINAL ISSIGNED BY BUILDING INSPECTOR. MICROFILMLu ' ARRANGE FOR INSPECTION BY PHONING 252-4505, ONE WORKING DAY BEFORE REQUIRED INSPECTION. z PLEASE GIVE JOB ADDRESS WHEN PHONING. - SEE PERMIT FOR EXPIRATION DATE - ELECTRIC PLUMBING MECHANICAL CONST. TAX IMPORTANT! PLEASE READ REVERSE SIDE BEFORE CALLING FOR FINAL INSPECTION. TOTAL OFFICE COPY